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Is invisible mental health care possible?

The Flemish Government Architect is currently working on the Care Pilot Projects. This is a cooperative agreement with the Minister of Welfare, the Care and Health Agency and the VIPA (Flemish Fund for Person-Based Infrastructure). The intention, in five pilot projects, is to lay the foundations for a new, generous and robust policy for care architecture in Flanders.(1)

The basis for these projects is the proposal for ‘invisible care’ drawn up by the Flemish Government Architect Peter Swinnen. The term is intended to provide for an appropriate architectural and spatial response to the new care relationships and care chains unfolding at the present time, partly influenced by Article 107.

In this framework of the socialisation of care, the proposal defines seven rules of thumb – what are called invisibility factors:

3. Create small scale: intimacy, security and domesticity make it possible to live with dignity

4. Dare to programme in an urban manner: the elderly and those in need of care deserve a place in the centre of the residential district

5. Make use of the private market: real investors make for social capital and spatial quality

6. Develop intelligent rules: rules should not be based on minimum scenarios, but should generate innovative design intelligence

7. Take up the challenge of design-based research: design freedom enables ambitious initiatives to be accepted

Obviously there is still little that can be said about the implementation of the proposal in the pilot projects. At the moment the question remains whether the proposal is sufficiently appropriate as a visionary framework for design and building assignments in the care sector. Another question is whether it will be able to command general legitimacy.

For the time being the proposal appears primarily to have been written on the basis of a spatial reflex. Peter Swinnen starts with the observation that care is part of an industrial complex. Care institutions present themselves as factories that comply only with an internal logic and do not enter into any relations with the outside world. The response to this situation is: ‘Invisible care is care that is no longer isolated but is integrated into social and urban life’.

The noble ambition becomes debatable when we read that the huge building programme in the care sector not only permits us to redefine care, but also to shape the town or city. This is very reasonable from the point of view of architectural or spatial policy. In Belgium’s tradition of liberal policy, a vigorous drive towards urban development is impossible without large scale programmes for public buildings. But the danger is that care issues become no more than an instrumental by-the-way in the context of lofty spatial aspirations.

Further, it is also striking that the proposal for invisible care is framed on the basis of the rapidly-growing market for residential care for the elderly. The proposal starts with the projection that by 2050 Belgium will have two million more over-60s than at present. While taking account of the need for the ability to live independently, the Flemish Government Architect is putting his money on integrated residential care zones. This means that care for the elderly will be expanded into a natural part of everyday urban life.

However, by focusing on so-called ‘grey gold’, the Flemish Government Architect is opting for the easiest route. How innovative will the pilot projects be in a sector that is generally quite normalised? A sector, moreover, in which the patient is emancipated – having now become a client – and, dependent on his own needs and desires, can choose from a varied range of possibilities. At present, it is above all service flats and secondary suites that minimise the clinical nature of care for the elderly.

The proposal for invisible care has to be applied to a more awkward design assignment to prove its use and advantages. In this regard mental health care seems like a more challenging choice. For various reasons, mental health care is still housed in an industrial complex that turns away from the inhabited world.

In the first place, from the patient’s point of view there is a need for low-stimulus environments. Integration of mental health care into the urban fabric is natural in volunteer aid and residential psychiatric care (PVTs). The question is whether the same ambition can be achieved in therapeutic and critical care – and whether it is also desirable. And what about the high-risk care in forensic psychiatry?

Secondly, from the perspective of society there is little tolerance for mental health care. The spatial separation of mental health care is a historical consequence of political and social displacement to the outskirts of the city. And the integration of mental health care thus demands pioneering thinking on spatial planning in general – which has to be acceptable to the public at large.

In addition, the dismantling of this segregated existence is not self-evident for the psychiatric institutions themselves. Their properties make up an exceptionally large financial and symbolic capital that cannot simply be thrown away. Scenarios for a spatial integration of mental health care should therefore also develop an outlook for the future of the institutions in rural settings.

Lastly, the market has little regard for the mental health sector. Private contractors and capital groups have little interest in serious and long-term care, more so in patients with lighter profiles. For example, the private market is very active in building and running service flats for elderly people.

In short, setting out a visionary framework for care architecture is best done in a sector that puts the listed invisibility factors to the test. This is the only way their application can lead to innovative design knowledge that can bring about a real and lasting change in the Flemish care landscape.